The Hierarchy of Evidence The Hierarchy of evidence is based on summaries from the National Health and Medical Research Council (2009), the Oxford Centre for Evidence-based Medicine Levels of Evidence (2011) and Melynyk and Fineout-Overholt (2011). Ι Evidence obtained from a systematic review of all relevant randomised control trials. ΙΙ Evidence obtained from at least one well designed randomised control trial. ΙΙΙ Evidence obtained from well-designed controlled trials without randomisation. IV Evidence obtained from well designed cohort studies, case control studies, interrupted time series with a control group, historically

controlled studies, interrupted time series without a control group or with case- series V Evidence obtained from systematic reviews of descriptive and qualitative studies VI Evidence obtained from single descriptive and qualitative studies VII Expert opinion from clinicians, authorities and/or reports of expert committees or based on physiology

Melynyk, B. & Fineout-Overholt, E. (2011). Evidence-based practice in nursing & healthcare: A guide to best practice (2nd ed.). Philadelphia: Wolters Kluwer, Lippincott Williams & Wilkins.

National Health and Medical Research Council (2009). NHMRC levels of evidence and grades for recommendations for developers of guidelines (2009). Australian Government: NHMRC. http://www.nhmrc.gov.au/_files_nhmrc/file/guidelines/evidence_statement_form.pdf

OCEBM Levels of Evidence Working Group Oxford (2011).The Oxford 2011 Levels of Evidence. Oxford Centre for Evidence-Based Medicine. http://www.cebm.net/index.aspx?o=1025

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Reference (include title, author, journal

title, year of publication, volume and issue, pages)

Evidence level (I-VII)

Key findings, outcomes or recommendations

Maisels, M.J. & McDonagh, A.F. (2008) Phototherapy for neonatal jaundice, The New England Journal of Medicine, 358;9: 920-8

II, V, VII Review article that includes clinical studies, clinical use of phototherapy, adverse effects of phototherapy, the presentation of formal non-evidenced based American Academy of Pediatrics guidelines, and expert opinion. Key findings: Phototherapy is effective in infants of any gestation to reduce serum bilirubin levels, as evidenced by the dramatic reduction in the number of exchange transfusions being done. Phototherapy in term and late-preterm infants is commenced at higher total serum bilirubin levels than in preterm infants. The efficacy of phototherapy depends on the irradiance and type of the light source, as well as the cause and severity of the hyperbilirubinaemia.

American Academy of Pediatrics Clinical Practice Guideline, Management of hyperbilirubinaemia in the newborn infant35 or more weeks of gestation, (2004), Pediatrics;114;297-316, 1138

IV, VII Clinical practice guideline from the AAP Subcommittee on Hyperbilirubinaemia Key findings: Protocols for the assessment of jaundice include obtaining a serum bilirubin measure for any neonate with jaundice evident in the first 24 hours age, and after this time, as per the recommendations adopted by the Health Care Facility. All bilirubin measures should be interpreted according to the neonate’s age in hours.

Scheidt, P.C., Bryla, D.A., Nelson, K.B., Hirtz, D.G., Hoffman, H.J. (1990) Phototherapy for neonatal hyperbilirubinaemia: Six-year follow up of the national institute of child health and human development clinical trial, Pediatrics; 85;455-463

II Key findings: phototherapy effectively controlled neonatal hyperbilirubinaemia without evidence of adverse outcome at 6 years of age, and was at least as effective as management with exchange transfusion alone.

NICE Clinical Guideline (2010) VII Key findings: Always use serum bilirubin measures in babies with jaundice in the first 24 hours of life, or in babies with jaundice who are less than 35 weeks gestational age. Serum bilirubin measures are to be used if a transcutaneous bilirubinometer is not available for measuring bilirubin levels in babies with a gestational age of 35 weeks or more, or a postnatal age of more than 24 hours. Ensure phototherapy equipment is maintained and used according to manufacturer’s guidelines. Use phototherapy when the serum bilirubin measurement is in the treatment threshold tables/graphs utiltised. Use conventional ‘blue light’ phototherapy or multiple phototherapy treatment for significant hyperbilirubinaemia in babies with a gestational age of 37 weeks or more.

Bhutani, V.K. & the Committee on Fetus and Newborn (2011), Pediatrics128;4; 1046-1052

II, VI, VII Key findings: Effectiveness of phototherapy devices is maximized by ensuring that the light source is not blocked from reaching the neonate, by maximizing the exposed body surface area to the light source, and by ensuring the irradiance meets recommended standards. Effectiveness of phototherapy is measured by demonstrating a decrease in total serum bilirubin concentrations during the first 4-6 hours of exposure.

Queensland Maternity and Neonatal Clinical Guideline (2009) Neonatal jaundice: prevention, assessment and management.

V, VII Comprehensive clinical guideline includes indications for exchange transfusion and discharge follow-up recommendations. Key findings: Jaundice may be a sign of serious illness in association with other findings. A total serum bilirubin level at or above the exchange transfusion level should be considered a medical emergency; multiple light phototherapy should be commenced immediately whilst further care is being arranged.